Journal of Clinical Oncology, Vol 11, 777-782, Copyright © 1993 by American Society of Clinical Oncology
Should the elderly receive chemotherapy for node-negative breast cancer? A cost-effectiveness analysis examining total and active life- expectancy outcomes
CE Desch, BE Hillner, TJ Smith and SM Retchin
Department of Internal Medicine, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298-0037.
PURPOSE: This study determines the survival benefit and cost- effectiveness
of adjuvant chemotherapy in elderly women with breast cancer. In addition,
the analysis measures the impact of substituting active life expectancy for
survival in the clinical decision. PATIENTS AND METHODS: Two cohorts of
women with estrogen receptor (ER)-negative, stage I breast cancer from age
60 to 80 years were monitored using a Markov process. One group received
standard chemotherapy following primary therapy, and the other had no
postoperative treatment. Data were derived from recently published clinical
trials and a major meta- analysis. Outcome included the average survival,
active life- expectancy, and incremental cost/quality-adjusted life-year
(cost/QALY). RESULTS: Adjuvant chemotherapy prolongs survival in older
women, but to a lesser extent compared with younger women. The average gain
in quality-adjusted months was 1.8 months in a 75-year-old cohort at a
cost/QALY of $4,400. These small benefits were not substantially altered
when univariate changes were made in toxicity, recurrence risk, or
effectiveness of chemotherapy. When active life expectancy replaced
survival as an end point, the benefit for 75-year-old women decreased to 2
weeks at a cost of more than $96,000/QALY. CONCLUSION: There is a small
survival benefit for adjuvant chemotherapy in elderly patients. The cost of
this benefit is high, but within the range of commonly reimbursed
procedures until a point between 75 and 80 years old. The use of active
life expectancy as the primary outcome reduces the benefit and adds to the
cost. If physicians and policymakers agree that active life expectancy is a
relevant outcome, withholding chemotherapy for patients > or = 70 years
old is a reasonable approach.
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